Sunday, 31 July 2011

Stones - Lithotomy

Carel van Savoyen’s Portrait of Jan de Doot,

holding the kidney stone he removed from himself.

Stones are sometimes formed inside hollow organs, such as the kidneys, bladder, and gallbladder. Unable to exit naturally through the urinary system or biliary tract they cause considerable pain and sometimes death. Lithotomy from Greek for "lithos" (stone) and "tomos" (cut), is a surgical method for their removal.

On the first of December 1739 a negro, of about 15 years of age, died in St George’s hospital. The preceding day the lateral operation had been performed on him, for extracting a stone, the symptoms of which he had laboured under for several years, and of which the surgeons were convinced, by the sounding of the probe. […] Many curious gentlemen were present at the aperture of the carcass; there was found in the internal and posterior lateral part of the bottom of the bladder, a bony cystis, as large as a chestnut, and full of a stony substance, which form’d a round hard body, that sounded against the point of the probe; this body was engaged in the internal membrane of the bladder, with which it was cover’d by a large base, which rose from the bottom of that organ, and rested on the rectum; so that, in the discharges of the excrements and the urine, and in certain situations of the body, it stopp’d up the entrance of the urethra, and irritated that orifice, so as to produce those symptoms which had been attributed to a stone in the bladder. (268-9)

Some days ago, M. Guerin, the father, shew’d me the bladder of a man of 50 years of age, who had been cut for the stone last year. He had found a great deal of resistance in introducing the probe into the bladder. The incision being made in the ordinary manner, he had introduced the pincers, and at once extracted two pieces of fungous excrescences of flesh, and thirteen stones, shaped like those of the patient I have before-mentioned, but smaller. He used injections, with a view to bring away a stone which he had touch’d with the the probe, but could not lay hold of it; the patient, however, died eight days after. Upon opening the carcass, twenty-seven stones, like the former, were found included in in particular cellules, some presenting one of their angles, and others one of their small faces to the mouths of their respective cellules. There was also on the right side of the bladder, an excrescence, in form of a mushroom, which in some measure stopp’d up the orifice of the bladder. (272)

From Memoirs of the RoyalAcademy of Surgery at Paris: containing a great variety of Cases in the chief branches of the Art, many of them very surprising and uncommon. Volume II (1750)

Memoir XII recounts a “Remarkable cure by cutting a new anus, and its mechanism” (247-63)

But the magnified images of stones are incredibly beautiful, as can be seen here.

Finally let's remind ourselves of the famous essayist Michel de Montaigne, whose affliction provided an opportunity to reflect on the misfortunes that accompany old age:

We must learn to suffer what we cannot evade; our life, like the harmony
of the world, is composed of contrary things—of diverse tones, sweet
and harsh, sharp and flat, sprightly and solemn: the musician who should
only affect some of these, what would he be able to do? he must know how
to make use of them all, and to mix them; and so we should mingle the
goods and evils which are consubstantial with our life; our being cannot
subsist without this mixture, and the one part is no less necessary to it
than the other. To attempt to combat natural necessity, is to represent
the folly of Ctesiphon, who undertook to kick with his mule.—[Plutarch,
How to restrain Anger, c. 8.]

I consult little about the alterations I feel: for these doctors take
advantage; when they have you at their mercy, they surfeit your ears with
their prognostics; and formerly surprising me, weakened with sickness,
injuriously handled me with their dogmas and magisterial fopperies—one
while menacing me with great pains, and another with approaching death.
Hereby I was indeed moved and shaken, but not subdued nor jostled from my
place; and though my judgment was neither altered nor distracted, yet it
was at least disturbed: 'tis always agitation and combat.

Now, I use my imagination as gently as I can, and would discharge it, if I
could, of all trouble and contest; a man must assist, flatter, and deceive
it, if he can; my mind is fit for that office; it needs no appearances
throughout: could it persuade as it preaches, it would successfully
relieve me. Will you have an example? It tells me: "that 'tis for my good
to have the stone: that the structure of my age must naturally suffer some
decay, and it is now time it should begin to disjoin and to confess a
breach; 'tis a common necessity, and there is nothing in it either
miraculous or new; I therein pay what is due to old age, and I cannot
expect a better bargain; that society ought to comfort me, being fallen
into the most common infirmity of my age; I see everywhere men tormented
with the same disease, and am honoured by the fellowship, forasmuch as men
of the best quality are most frequently afflicted with it: 'tis a noble
and dignified disease: that of such as are struck with it, few have it to
a less degree of pain; that these are put to the trouble of a strict diet
and the daily taking of nauseous potions, whereas I owe my better state
purely to my good fortune; for some ordinary broths of eringo or
burst-wort that I have twice or thrice taken to oblige the ladies, who,
with greater kindness than my pain was sharp, would needs present me half
of theirs, seemed to me equally easy to take and fruitless in operation,
the others have to pay a thousand vows to AEsculapius, and as many crowns
to their physicians, for the voiding a little gravel, which I often do by
the aid of nature: even the decorum of my countenance is not disturbed in
company; and I can hold my water ten hours, and as long as any man in
health. 'The fear of this disease,' says my mind, 'formerly affrighted
thee, when it was unknown to thee; the cries and despairing groans of
those who make it worse by their impatience, begot a horror in thee. 'Tis
an infirmity that punishes the members by which thou hast most offended.
Thou art a conscientious fellow;'

Quae venit indigne poena, dolenda venit:

"We are entitled to complain of a punishment that we have not
deserved." (Ovid, Heroid., v. 8.)

consider this chastisement: 'tis very easy in comparison of others, and
inflicted with a paternal tenderness: do but observe how late it comes; it
only seizes on and incommodes that part of thy life which is, one way and
another, sterile and lost; having, as it were by composition, given time
for the licence and pleasures of thy youth. The fear and the compassion
that the people have of this disease serve thee for matter of glory; a
quality whereof if thou bast thy judgment purified, and that thy reason
has somewhat cured it, thy friends notwithstanding, discern some tincture
in thy complexion. 'Tis a pleasure to hear it said of oneself what
strength of mind, what patience! Thou art seen to sweat with pain, to turn
pale and red, to tremble, to vomit blood, to suffer strange contractions
and convulsions, at times to let great tears drop from thine eyes, to
urine thick, black, and dreadful water, or to have it suppressed by some
sharp and craggy stone, that cruelly pricks and tears the neck of the
bladder, whilst all the while thou entertainest the company with an
ordinary countenance; droning by fits with thy people; making one in a
continuous discourse, now and then making excuse for thy pain, and
representing thy suffering less than it is. Dost thou call to mind the men
of past times, who so greedily sought diseases to keep their virtue in
breath and exercise? Put the case that nature sets thee on and impels thee
to this glorious school, into which thou wouldst never have entered of thy
own free will. If thou tellest me that it is a dangerous and mortal
disease, what others are not so? for 'tis a physical cheat to expect any
that they say do not go direct to death: what matters if they go thither
by accident, or if they easily slide and slip into the path that leads us
to it? But thou dost not die because thou art sick; thou diest because
thou art living: death kills thee without the help of sickness: and
sickness has deferred death in some, who have lived longer by reason that
they thought themselves always dying; to which may be added, that as in
wounds, so in diseases, some are medicinal and wholesome. The stone is
often no less long-lived than you; we see men with whom it has continued
from their infancy even to their extreme old age; and if they had not
broken company, it would have been with them longer still; you more often
kill it than it kills you. And though it should present to you the image
of approaching death, were it not a good office to a man of such an age,
to put him in mind of his end? And, which is worse, thou hast no longer
anything that should make thee desire to be cured. Whether or no, common
necessity will soon call thee away. Do but consider how skilfully and
gently she puts thee out of concern with life, and weans thee from the
world; not forcing thee with a tyrannical subjection, like so many other
infirmities which thou seest old men afflicted withal, that hold them in
continual torment, and keep them in perpetual and unintermitted weakness
and pains, but by warnings and instructions at intervals, intermixing long
pauses of repose, as it were to give thee opportunity to meditate and
ruminate upon thy lesson, at thy own ease and leisure. To give thee means
to judge aright, and to assume the resolution of a man of courage, it
presents to thee the state of thy entire condition, both in good and evil;
and one while a very cheerful and another an insupportable life, in one
and the same day. If thou embracest not death, at least thou shakest hands
with it once a month; whence thou hast more cause to hope that it will one
day surprise thee without menace; and that being so often conducted to the
water-side, but still thinking thyself to be upon the accustomed terms,
thou and thy confidence will at one time or another be unexpectedly wafted
over. A man cannot reasonably complain of diseases that fairly divide the
time with health.

I am obliged to Fortune for having so often assaulted me with the same
sort of weapons: she forms and fashions me by use, hardens and habituates
me, so that I can know within a little for how much I shall be quit. For
want of natural memory, I make one of paper; and as any new symptom
happens in my disease, I set it down, whence it falls out that, having now
almost passed through all sorts of examples, if anything striking
threatens me, turning over these little loose notes, as the Sybilline
leaves, I never fail of finding matter of consolation from some favourable
prognostic in my past experience. Custom also makes me hope better for the
time to come; for, the conduct of this clearing out having so long
continued, 'tis to be believed that nature will not alter her course, and
that no other worse accident will happen than what I already feel. And
besides, the condition of this disease is not unsuitable to my prompt and
sudden complexion: when it assaults me gently, I am afraid, for 'tis then
for a great while; but it has, naturally, brisk and vigorous excesses; it
claws me to purpose for a day or two. My kidneys held out an age without
alteration; and I have almost now lived another, since they changed their
state; evils have their periods, as well as benefits: peradventure, the
infirmity draws towards an end. Age weakens the heat of my stomach, and,
its digestion being less perfect, sends this crude matter to my kidneys;
why, at a certain revolution, may not the heat of my kidneys be also
abated, so that they can no more petrify my phlegm, and nature find out
some other way of purgation. Years have evidently helped me to drain
certain rheums; and why not these excrements which furnish matter for
gravel? But is there anything delightful in comparison of this sudden
change, when from an excessive pain, I come, by the voiding of a stone, to
recover, as by a flash of lightning, the beautiful light of health, so
free and full, as it happens in our sudden and sharpest colics? Is there
anything in the pain suffered, that one can counterpoise to the pleasure
of so sudden an amendment? Oh, how much does health seem the more pleasant
to me, after a sickness so near and so contiguous, that I can distinguish
them in the presence of one another, in their greatest show; when they
appear in emulation, as if to make head against and dispute it with one
another! As the Stoics say that vices are profitably introduced to give
value to and to set off virtue, we can, with better reason and less
temerity of conjecture, say that nature has given us pain for the honour
and service of pleasure and indolence. When Socrates, after his fetters
were knocked off, felt the pleasure of that itching which the weight of
them had caused in his legs, he rejoiced to consider the strict alliance
betwixt pain and pleasure; how they are linked together by a necessary
connection, so that by turns they follow and mutually beget one another;
and cried out to good AEsop, that he ought out of this consideration to
have taken matter for a fine fable.

The worst that I see in other diseases is, that they are not so grievous
in their effect as they are in their issue: a man is a whole year in
recovering, and all the while full of weakness and fear. There is so much
hazard, and so many steps to arrive at safety, that there is no end on't
before they have unmuffled you of a kerchief, and then of a cap, before
they allow you to walk abroad and take the air, to drink wine, to lie with
your wife, to eat melons, 'tis odds you relapse into some new distemper.
The stone has this privilege, that it carries itself clean off: whereas
the other maladies always leave behind them some impression and alteration
that render the body subject to a new disease, and lend a hand to one
another. Those are excusable that content themselves with possessing us,
without extending farther and introducing their followers; but courteous
and kind are those whose passage brings us any profitable issue. Since I
have been troubled with the stone, I find myself freed from all other
accidents, much more, methinks, than I was before, and have never had any
fever since; I argue that the extreme and frequent vomitings that I am
subject to purge me: and, on the other hand, my distastes for this and
that, and the strange fasts I am forced to keep, digest my peccant
humours, and nature, with those stones, voids whatever there is in me
superfluous and hurtful. Let them never tell me that it is a medicine too
dear bought: for what avail so many stinking draughts, so many caustics,
incisions, sweats, setons, diets, and so many other methods of cure, which
often, by reason we are not able to undergo their violence and
importunity, bring us to our graves? So that when I have the stone, I look
upon it as physic; when free from it, as an absolute deliverance.

And here is another particular benefit of my disease; which is, that it
almost plays its game by itself, and lets 'me play mine, if I have only
courage to do it; for, in its greatest fury, I have endured it ten hours
together on horseback. Do but endure only; you need no other regimen play,
run, dine, do this and t'other, if you can; your debauch will do you more
good than harm; say as much to one that has the pox, the gout, or hernia!
The other diseases have more universal obligations; rack our actions after
another kind of manner, disturb our whole order, and to their
consideration engage the whole state of life: this only pinches the skin;
it leaves the understanding and the will wholly at our own disposal, and
the tongue, the hands, and the feet; it rather awakens than stupefies you.
The soul is struck with the ardour of a fever, overwhelmed with an
epilepsy, and displaced by a sharp megrim, and, in short, astounded by all
the diseases that hurt the whole mass and the most noble parts; this never
meddles with the soul; if anything goes amiss with her, 'tis her own
fault; she betrays, dismounts, and abandons herself. There are none but
fools who suffer themselves to be persuaded that this hard and massive
body which is baked in our kidneys is to be dissolved by drinks;
wherefore, when it is once stirred, there is nothing to be done but to
give it passage; and, for that matter, it will itself make one.
I moreover observe this particular convenience in it, that it is a disease
wherein we have little to guess at: we are dispensed from the trouble into
which other diseases throw us by the uncertainty of their causes,
conditions, and progress; a trouble that is infinitely painful: we have no
need of consultations and doctoral interpretations; the senses well enough
inform us both what it is and where it is.

By suchlike arguments, weak and strong, as Cicero with the disease of his
old age, I try to rock asleep and amuse my imagination, and to dress its
wounds. If I find them worse tomorrow, I will provide new stratagems. That
this is true: I am come to that pass of late, that the least motion forces
pure blood out of my kidneys: what of that? I move about, nevertheless, as
before, and ride after my hounds with a juvenile and insolent ardour; and
hold that I have very good satisfaction for an accident of that
importance, when it costs me no more but a dull heaviness and uneasiness
in that part; 'tis some great stone that wastes and consumes the substance
of my kidneys and my life, which I by little and little evacuate, not
without some natural pleasure, as an excrement henceforward superfluous
and troublesome. Now if I feel anything stirring, do not fancy that I
trouble myself to consult my pulse or my urine, thereby to put myself upon
some annoying prevention; I shall soon enough feel the pain, without
making it more and longer by the disease of fear. He who fears he shall
suffer, already suffers what he fears. To which may be added that the
doubts and ignorance of those who take upon them to expound the designs of
nature and her internal progressions, and the many false prognostics of
their art, ought to give us to understand that her ways are inscrutable
and utterly unknown; there is great uncertainty, variety, and obscurity in
what she either promises or threatens. Old age excepted, which is an
indubitable sign of the approach of death, in all other accidents I see
few signs of the future, whereon we may ground our divination. I only
judge of myself by actual sensation, not by reasoning: to what end, since
I am resolved to bring nothing to it but expectation and patience? Will
you know how much I get by this? observe those who do otherwise, and who
rely upon so many diverse persuasions and counsels; how often the
imagination presses upon them without any bodily pain. I have many times
amused myself, being well and in safety, and quite free from these
dangerous attacks in communicating them to the physicians as then
beginning to discover themselves in me; I underwent the decree of their
dreadful conclusions, being all the while quite at my ease, and so much
the more obliged to the favour of God and better satisfied of the vanity
of this art.